Counties Step Up to Reduce Mentally Ill People in Jails

The Stepping Up Initiative took a big step forward with its summit last April in Washington, D.C. Now, many attendees are in mid-stride as they implement what they learned about ways to reduce the number of people with mental illness in America’s jails.

The summit brought together police, sheriffs, mental health professionals, and local county government officials from 50 counties around the country to thrash out ideas to apply back home in counties large or small.

Counties that participate in the Stepping Up Initiative make a formal commitment to address the problem, then delve into pragmatic policies, programs, and best practices.

After that, the real work begins.

“We envision Stepping Up as a five-to-10-year process,” said Fred Osher, M.D., director of Health Systems and Services Policy at the Council of State Governments Justice Center, a cosponsor of the initiative with the National Association of Counties and the American Psychiatric Association Foundation (APAF). “We are gratified that so many counties have moved forward with planning, and that three-quarters have held regular stakeholder meetings.”

David Hathcox

Recent discussions with attendees from around the country find that many of them are working in parallel, taking similar steps forward and meeting similar challenges.

“Attending the conference gave us a more national view,” said Geri Marcus, M.Ed., executive director of Willapa Behavioral Health in Raymond, Wash.

The Stepping Up approach involves identifying people with mental illness as early as possible in their interaction with the criminal justice system and, when possible, diverting them to treatment rather than incarceration. Those who cannot be diverted because of the severity of their crimes require treatment in jails and a planned transition to community services after discharge.

The high costs of the revolving-door pattern of arrest, trial, incarceration, treatment in jail, release, and re-arrest finally led county officials around the United States to consider alternatives.

Simple as it sounds, the first step may be getting every agency involved into the same room at the same time.

In fact, the large group interaction that was a central part of the Washington summit is reflected in the effort to convene representatives from across local jurisdictions, said APAF Executive Director Daniel Gillison, the former director for county solutions and innovations at the National Association of Counties.

“What’s important is that the people who want to come up with solutions are working together in teams, rather than silos,” said Gillison.

Those on the front lines agree.

“We’re bringing everyone together and talking about issues,” said Tiana Glenna, M.S., criminal justice collaborating council manager in Eau Claire County, Wis. “The walls of separation are starting to come down. Meeting together reaffirmed the movement, the tools, and the programs that we have to work with in the county and showed us what new resources and processes we have to develop here.”

Connecting with her peers from other agencies was crucial, said Roseanne McPhail, B.A., coordinator of the Justice–Mental Health Collaboration grant in Pacific County, Wash., another attendee.

“You have to speak the language of whoever you’re talking to, whether that’s a police chief, the school superintendent, a hospital director, a housing director, a prosecutor, or an elected official,” said McPhail in an interview.

Making those personal connections may be easier in a county of 20,000 citizens, but the broader lesson can be applied anywhere.

Psychiatrist Frank Pieri, M.D., of Alamogordo, in Otero County, N.M., has been working with several agencies there to set up a mental health court that would include a jail diversion program.

“We are also in the process of meeting with other agencies and individuals in neighboring Lincoln and Dona Ana counties, attempting to get a grant for jail diversion,” he told Psychiatric News. “We are working at it, but progress is not as fast as we would like primarily due to limited resources of time and money.”

Local funding is indeed a recurrent problem, agreed Osher. Counties spend more than $70 billion a year on court processing. However, redirecting some of that money into community mental health or social services is no simple matter.

“Everybody is struggling with an underfunded behavioral health system,” said Osher. Some of the answer may lie in finding short-term funds to first divert mentally ill defendants from the criminal justice system, which produces larger, longer-term savings that can be reinvested in services.

Keeping the voters informed is also important.

“We have done a good job of educating the public about what they’re getting for their tax dollars,” said John Miller, who recently retired as a supervisor in Black Hawk County, Iowa. “People squawk, but they know what they’re getting.”

Whether approaching state legislators, county councils, or foundations, it helps to go armed with data to buttress proposals.

“We’re still doing some planning, gathering evidence, and looking at statistics before implementing any specific programming,” said Kathryn Schauf, M.P.A., the Eau Claire County administrator.

“We had to agree on common definitions of terms like ‘recidivism’ and ‘mental illness’ so we could collect consistent data,” said McPhail. Pacific County revised its screening protocol for mental illness and substance use disorders beginning last July 1 to use more consistent language. Soon, the local police will start using a standard form to capture information about suspects who may be mentally ill so they can be referred to Willapa Behavioral Health, the local mental health provider.

“We’re about 30 percent along the way to where we want to be,” said Iowa’s Miller. “The sheriff, county attorney, public defender, and a couple of judges have met to determine a place where individuals—often with mental illnesses—who have minor offenses can be released from jail within 24 hours rather than spend eight to 10 days waiting for a court appearance. Right now, jail is the cheapest place to keep them.”

Developing a range of community alternatives to jail is essential, however. Having a crisis center is not enough.

“Diversion is only part of what’s needed for recovery,” said psychiatrist Keith McCoy, M.D., regional medical director for Cardinal Innovations Health Care in Chapel Hill, N.C.

“Low-barrier, stable, supported housing may be the most important next step,” said McCoy, whose job includes community integration of mental health. “Ultimately you need to have other systems in place and work with the mental health system—housing, education, clothes, food, and employment.”

(McCoy was joined in his work on Stepping Up in Alamance County by Robin Huffman, executive director of the North Carolina Psychiatric Association. Huffman hopes that state psychiatric associations will eventually become involved in the Stepping Up Initiative.)

Often, local mental health systems are stressed by the nationwide deficit in the behavioral health workforce. When the closest crisis center is an hour and a half away, a social worker called out at night by the police to deal with a person in crisis still has to put in a regular eight-hour shift the next day, said McPhail.

The shortage of beds is another stressor, she pointed out. “When a person in crisis is taken to a local hospital and needs inpatient care, someone from Willapa must telephone around the state to find a facility with an open bed.”

Finally, Stepping Up participants are doing their best to spread the word to other jurisdictions.

“We regularly meet with human service directors from around the state,” said Diane Cable, M.S.W., human services director for Eau Claire County. “That’s had the indirect effect of moving many of the ideas that are part of Stepping Up beyond the criminal justice system and into other areas covered by their departments.”

New Mexico’s Pieri agreed. He hopes to have a local conference this spring with all the key players in the three area counties. They will invite a judge or team of individuals who have set up a successful mental health court and jail diversion program in a rural county to offer some guidance.

Overall, this long journey has begun with some encouraging first steps, but it’s a long way from completion.

“It may seem obvious, but it’s still important to remember that this stuff is not easy,” said Cable. “It is complex and happens on multiple levels. There are no simple fixes here.” ■